CE and PRICE

Course Description:
Since the mid 1980s, psychological research on forgiveness has seen an accelerating growth. This course reviews the published research literature on forgiveness including its mental and physical health benefits, cognitive and neuropsychological aspects, and practices that enhance forgiveness interventions.

The Boom in Forgiveness Research

According to psychiatrist Prakash Gangdev, the current boom in research on forgiveness was first triggered by the publication in 1984 of a book titled Forgive and Forget: Healing the Hurts We Don’t Deserve, by Christian theologian Lewis B. Smedes. Until that time forgiveness was primarily seen as a matter for religion and philosophy. But in the mid 80’s, along with the emergence of the Positive Psychology movement, forgiveness found a new home within psychology and research on forgiveness began in earnest. (For Gangdev’s 2009 full article written to raise awareness of the therapeutic value of forgiveness among psychiatrists, see Gandev, P (2009) Forgiveness: A note for psychiatrists. Indian J of Psychiatry 51(2)153-156.) By 2010, in an introduction to an entire issue of the Journal of Mental Health Counseling devoted to forgiveness in therapy, Nathaniel Wade would report that there were over 1000 published psychological research articles on forgiveness. (Wade, N (2010) Introduction to the Special Issue on Forgiveness in Psychotherapy. Journal of Mental Health Counseling, 32 (1) p. 1.)

While also noting the lack of a consensus definition, Denham et al. propose that any psychological definition informing the assessment of forgiveness should also specifically include the “emotional, cognitive, motivational, and behavioral elements of forgiveness.” For their rather lengthy clinical definition, see their chapter “Emotional Development and Forgiveness in Children: Emerging Evidence,” in Worthington EL (2005). Handbook of Forgiveness New York, Routledge, p. 129.

The situation regarding a working definition is further complicated by the fact that research subjects tend to reflect their cultural heritage. Two studies, one by Kadiangandu, JK, Gauché, M, Vinsonneau, G, and Mullet, E (2007) (Conceptualizations of forgiveness: collectivist-Congolese versus individualist-French viewpoints. Journal of Cross-Cultural Psychology, 38: 432-437) and another by Bagnulo, Muñoz-Sastre, and Mullet show that depending on the culture, forgiveness could be conceived as intrapersonal or interpersonal. (Bagnulo, A, Muñoz-Sastre, MT; Mullet, E, (2009), Conceptualizations of forgiveness: a Latin America-Western Europe comparison. Universitas Psychologica, 8 (3), pp. 673-682.) In these studies, those respondents with western European background, representatives of a more “individualistic” culture, viewed forgiveness as an intra-personal matter, occurring primarily within the personal experience of the wronged party. By contrast, those from cultures that could be described as “collectivistic,” tended to see forgiveness in interpersonal terms that include reconciliation with the offender. Bagnulo et al. see clinical implications, concluding that before introducing interventions designed to facilitate forgiveness, any disparity between the clinician’s and client’s notions of forgiveness may need to be addressed.

Topics in Forgiveness Research

Beyond the issue of definition and culture, forgiveness is a complex, multi-faceted topic. Can forgiveness be trained? Is individual therapy the most effective therapeutic approach or do psycho-educational groups work better? Initially seen as part of Positive Psychology’s goal of enhancing human wellness or flourishing, can forgiveness be an effective part of treatment for mental health issues such as depression or anxiety? Research has begun to provide answers to these and other important clinical questions.

Meta-analyses of Forgiveness Research

In the second forgiveness lesson we looked at the first meta-analysis of truly empirical forgiveness research, conducted by Enright and Baskin. (Baskin TW and Enright , RD (2004). Intervention studies on forgiveness: A meta-analysis. J of Counseling Psych, 82 (1) 79-90.) Since their 2004 study, there have been several newer meta-analyses that incorporate the extensive array of more recent research that have largely affirmed their conclusions. For example, in one such analysis completed in 2009, Rainey reported finding that while both individual and group interventions offered benefits to clients, individual interventions were more effective. In addition, those interventions lasting longer than 6 weeks worked best.

In a 2008 study, Lundahl et al. reviewed reports of process-based forgiveness interventions. They found that individual interventions were four times as effective as group interventions and also concluded that longer interventions produced stronger results. When they segregated out studies with “clinically distressed” subjects, the benefits were a full two standard deviations higher for those receiving forgiveness interventions than for the controls. Lundahl et al.’s meta-analysis also showed that the forgiveness interventions they studied work equally well for men and women, all minority groups, and across all ages. One clinically relevant difference they did uncover is that forgiveness interventions seem to work a bit better when the transgression is more specific (e.g., incest or abortion) rather than a habitual behavior (e.g., lack of love from a parent.) (Lundahl, BW, Taylor, MJ, Stevenson, R, Roberts, KD (2008). Process-based forgiveness interventions: A meta-analysis. Research on Social Work Practice 18 (5): 465-478.)

In their 2010 article, detailing the most extensive meta-analysis of forgiveness research to date, Fehr, Gelfand, and Nag analyzed 175 forgiveness studies with over 26,000 participants. While generally supporting Lundahl et al.’s conclusions, one interesting result of Fehr et al.’s study concerns the difference between interventions based on constructed scenarios versus remembered incidents from the research subjects’ lives. In the studies using constructed scenarios, the subjects’ beliefs had a stronger impact on their expressed willingness to forgive than did their affect. However in studies where remembered wrongs were used, the willingness to forgive was more clearly mediated by the subject’s emotions. This conclusion is of particular interest to clinicians. In the clinical setting, both group and individual forgiveness interventions, by their nature and intent, target real life transgressions experienced by clients. As such, working with affect is likely to be an important element of any successful clinical forgiveness intervention. (Fehr R, Gelfand, MJ, and Nag, M (2010) The road to forgiveness: A meta-analytic synthesis of its situational and dispositional correlates. Psych Bull 136 (5): 894-914)

The Mental Health Benefits of Forgiveness

“To forgive is to set a prisoner free and discover that the prisoner was you.” Lewis B. Smedes, Christian theologian

Increasingly researchers have turned their attention to the study of the mental and physical health benefits of forgiveness. Two general kinds of research have been used in this investigation. They attempt to answer two different questions. First, are people who are naturally inclined to forgive mentally and physically healthier than those who are not? In studies designed to answer this question, researchers measured their subjects’ natural inclination to forgive, or trait forgiveness, and compared that factor with other mental or physical health indicators. The second research question asks if forgiveness interventions improve the mental and physical health of those who receive them. Here researchers measure mental and physical health factors pre- and post-intervention and compare the results with control groups who did not receive the intervention.

Several studies that have compared the mental health of people who have a natural propensity to forgive (trait forgiveness) with those who are not so inclined have shown that trait forgiveness has the following mental health benefits:

These four studies offer strong empirical evidence that those predisposed towards forgiveness are more likely to experience better mental health in various ways. But do forgiveness interventions that increase one’s ability to forgive also improve mental health?

In a 1996 study of Caucasian female incest survivors aged 24-54 conducted by Freedman and Enright, participants attended weekly individual sessions for an average of 14 months focused on forgiving their abuser. Compared to a control group, they showed gains in forgiveness and hope together with significant decreases in anxiety and depression. (Freedman, SR, Enright, RD (1996). Forgiveness as an intervention goal with incest survivors. J of Consult and Clin Psych, 64(5): 983-992.) Reed and Enright’s 2006 study used a similar intervention with women victims of spousal emotional abuse. Their increased ability to forgive was associated with considerable improvements in “depression, trait anxiety, posttraumatic stress symptoms, self esteem, environmental mastery and finding meaning in suffering.” These gains were maintained eight months post-treatment. (Reed, GL, Enright, RD, (2006). The effects of forgiveness therapy on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. J of Consult and Clin Psych, 74(5): 920-929.) In 1997, Coyle and Enright provided 12 weekly individual 90 minute sessions using a process-based forgiveness protocol to a group of men who expressed being hurt by their partner’s decision to have an abortion. This group showed increased forgiveness as well as “significant reductions in anxiety, anger, and grief.” (Coyle, C, Enright, RD (1997). Forgiveness intervention with postabortion men. J of Consult and Clin Psych 65(6): 1042-1046.)

Meta-analysis of research on the mental health effects of forgiveness interventions confirms the general direction of these individual studies. Lundahl’s 2008 overview of forgiveness interventions described above revealed a large effect size for both increased ability to forgive and increased positive affect. The results for self-esteem and reduced negative affect demonstrated a medium effect size. In addition, those receiving forgiveness interventions showed significantly reduced depression and anxiety, with results sustained at follow-up assessments as long as 4 months after the intervention. (Lundahl, BW, Taylor, MJ, Stevenson, R, Roberts, KD (2008). Process-based forgiveness interventions: A meta-analysis. Research on Social Work Practice 18 (5): 465-478.)

All in all, the research is painting a consistent and increasingly clear picture. People who forgive enjoy better mental than those who don’t. And even more important for clinicians, forgiveness interventions both increase the ability to forgive and catalyze improvement in a wide range of mental health factors. Perhaps most notably, the research shows that an improved ability to forgive results in decreased depression and anxiety.

Physical Health Benefits of Forgivensss

“The man who opts for revenge should dig two graves.” (A Chinese Proverb)

For the past decade there has been a growing recognition of the role of religiosity as positive factor in health and well-being. The Eastern aphorism above strongly suggests that forgiveness is included in this mix. But what does science tell us? Again the research is divided into two categories: those studies exploring the correlations between a natural propensity to forgive and physical health on the one hand, and those that look at the physical health benefits of forgiveness interventions on the other.

Some researchers have focused their efforts on the effects of forgiveness on specific medical issues. Results of such studies have shown that the inclination to forgive was associated with:

healthier ratios of both total to HDL cholesterol and LDL to HDL cholesterol. Given both their psychological (lower levels of stress, anxiety and depression) and physiological findings, the authors of this study concluded that “forgiveness may be associated with reduced risk for future cardiovascular events.” (Friedberg, JP, Suchday, S, and Srinivas, VS (2009). Relationship between forgiveness and psychological and physiological indices in cardiac patients. International J of Behav. Med. 16 (3): 205-211.)

As with the mental health benefits, much of the research has focused on the impact of trait forgiveness on physical health. Again we might wonder if forgiveness interventions actually make people physically healthier. To date (2011) a few studies have been completed which begin to provide answers to this question. In 2009, Waltman et al. examined the effects of a forgiveness intervention on problems involving blood circulation to the heart. Patients who showed anger-induced reductions of blood flow to the heart (myocardial perfusion) were given 10 weekly individual psychotherapy sessions focused on forgiveness. Their post-intervention and 10-week follow-up measures for myocardial perfusion were markedly reduced compared to a control group. (Waltman MA, Russell DC, Coyle CT, Enright RD, Holter AC, Swoboda C (2009). The effects of a forgiveness intervention on patients with coronary artery disease.Psychol Health 24(1):11-27.)

Factors Linking the Mental and Physical Health Benefits of Forgiveness

Given the growing evidence of the robust link between mental health and physical health, it is perhaps not surprising that forgiveness, which contributes strongly to mental well-being, has a similar impact on the body. But what is the link between forgiveness and physical well-being? Lawler et al. explored the mechanisms by which forgiveness led to physical health benefits. In her report, published in 2005, she examined four possible pathways: spirituality, improved social skills, reduction in negative affect, and reduction in stress. Her findings support the conclusion that reductions in negative affect and stress were the most strongly associated with both forgiveness and its positive physical health benefits. (Lawler KA, Younger JW, Piferi RL, Jobe RL, Edmondson, KA, and Jones WH (2005). The Unique Effects of Forgiveness on Health: An Exploration of Pathways. J of Behav Med 28 (2): 157-167.)

Then, in several 2010 studies, Lawler-Row further refined her research. She examined three related dimensions of forgiveness, finding that feeling forgiven by God had the strongest forgiveness-related health-mediating effect while self-forgiveness and forgiveness of others also contributed to the positive physical health effects of religiosity. Lawler-Row KA (2010). Forgiveness as a mediator of the religiosity—health relationship . Psychology of Religion and Spirituality 2(1): 1-16.)

The Motivation to Forgive

Traditionally the motivation to forgive has come from religious views, social norms, relationship imperatives, or dispositional factors. As forgiveness moves into the field of psychology, the situation may be changing to some extent. In light of the relatively recent research on the mental and physical health benefits for the one forgiving, new motivational dimensions for the cultivation of this age-old virtue are emerging. Clinicians may now find themselves approached by clients who want help forgiving for mental or physical health reasons, or may be motivated, themselves, to suggest forgiveness interventions to their clients for these same reasons. These new motivational dimensions are explicitly emphasized in the following 3 minute video in which Everett Worthington encourages forgiveness by summarizing the negative effects of unforgiveness from the physical, mental, social, and spiritual (Christian) perspectives.

A Useful Theoretical Perspective: The Developmental Stages of the Motivation to Forgiveness

The issue of motivation to forgive has been examined by Denham et al. from a developmental perspective. They have suggested that there is a natural continuum that describes a maturing motivational relationship to forgiveness from retribution to unconditional love. They summarize this theory as follows:

The initial stage depicts forgiveness as contingent on a level of revenge equal to the hurt cause by the offender. In the second, reciprocal forgiveness stage, one will forgive if the offender makes restitution for the offense or if forgiving will relieve guilt. The third stage of forgiveness emphasizes the expectation of others. In the fourth stage forgiveness, society’s expectations and religion are paramount influences. Individuals at the fifth stage reason in ways that maintain societal unity. In the final stage, forgiveness is an unconditional gift given in love by the victim. (Denham, et al., 2005, p. 132)

This continuum may provide clinicians with a useful yardstick with which to measure their clients’ developing capacity to forgive.

Factors that Mediate Forgiveness

Given the growing evidence of the benefits of forgiveness, psychologists have been increasingly interested in what factors facilitate the ability to forgive. Research targeting a number of different possible forgiveness mediators has already begun. This research has focused on several general areas. Some researchers have looked at practices that might be included in forgiveness interventions to enhance their efficacy. Others have looked at the relationship between specific cognitive capacities and the propensity to forgive.

Practices That Enhance Forgiveness Interventions

Two practices show promise as possible additions to forgiveness interventions: journaling and meditation. In 2006, McCullough, Root, and Cohen reported on the use of a writing intervention on the ability to forgive. They gave one group the counterintuitive assignment to write about the benefits of a transgression they had personally experienced while other groups wrote about the traumatic aspects of a recent transgression or about a non-transgression topic. Those journaling about personal benefits showed a greater gain in their ability to forgive than did the other two groups. Their results suggest that writing exercises focused on “benefit-finding may be a unique and useful addition to efforts to help people forgive interpersonal transgressions through structured interventions.” (McCullough ME. Root LM, and Cohen AD (2006). Writing about the benefits of an interpersonal transgression facilitates forgiveness. J of Consult and Clin Psych 74 (5): 887-897.)

Several studies suggest that meditation practice may facilitate forgiveness. In 2008, Oman et al. studied the effects of meditation on the abilities of college students to forgive. Students were taught either Mindfulness-Based Stress Reduction (MBSR) (LESSON LINK) or the Easwaran Eight Point Program, a meditation-based spiritual intervention. The students’ ability to forgive, measured from self-reports from both intervention groups, was compared to a wait-list control group. Both intervention groups showed greater ability to forgive. Their stress was also measurably reduced. Oman D, Shapiro S, Thoresen CE, Plante TG, Flinders T (2008). Meditation lowers stress and supports forgiveness among college students: A randomized controlled trial. J of Am College Health 56(5): 569-578.

Jankowski and Sandage’s work shows an optimistic link between meditation and forgiveness which they see mediated by the positive effect of meditation on hope and attachment style. (Jankowski PJ. Sandage, SJ (2011). Meditative prayer, hope, adult attachment, and forgiveness: A proposed model. Psychology of Religion and Spirituality 3 (2): 115-131.) Orcutt notes that forgiveness interventions have much in common with acceptance-based models of therapy, such as Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT) and Mindfulness-Based Cognitive Therapy (MBCT). (For information about these therapies see the lessons on them in the “Meditation and Mental Health” curriculum [link].) As she puts it

… both models articulate that the first step in the process toward forgiveness is fully experiencing the negative emotions and pain associated with the offense. The ability to be present with a painful experience without altering or denying the pain is a key component of acceptance-based approaches.

In fact, some forgive ness interventions already do explicitly incorporate forms of meditation. See Forgiveness Lesson II for a description of Fred Luskin’s psycho-educational approach to teaching forgiveness that utilizes mindfulness and Buddhist lovingkindness meditation. For an example of a guided meditative practice similar in style to those used in MBSR that integrates mindfulness and forgiveness and could be used in a psychotherapeutic context, go to [link] and select “Mindfulness and Forgiveness, Part 1.” (20 mins.) by Boulder, CO, psychotherapist, David Robbins.

Cognitive Elements of Forgiveness

Pronk, Karremans, and Overbeek’s 2010 study focuses on the role of executive function in the process leading to forgiveness. They define executive function as “a group of cognitive control processes working together to regulate and shape behavior, thoughts, and feelings in a goal-directed manner.” In four discrete experiments they found that the stronger the executive function the greater the likelihood of forgiveness. However they also noticed that this causal relationship was dependent on the severity of the transgression. The more severe the transgression, the more strongly executive function predicted the likelihood of forgiveness. Wondering why this should be the case, they discovered that rumination was the link: the more severe the offense, the more intense the rumination. Their experiments showed that executive function promotes forgiveness by controlling rumination. (Pronk TM. Karremans JC, Overbeek G, Vermulst, AA, Wigboldus, DHJ (2010). What it takes to forgive: When and why executive functioning facilitates forgiveness. J of Personality and Soc Psych 98( 1): 119-131.)

McCullough, Bono, and Root (2007) also explored the relationship between rumination and forgiveness in a study that highlights the interplay between the cognitive and affective aspects of experience. In their 2007 study, they found that increases in ruminative thinking (mediated by anger, but not by fear) about a transgression predicted reduced ability to forgive. However, the reverse, increased forgiveness leading to decreased rumination, did not hold true. Both these studies suggest that clinically addressing ruminative thinking, especially the anger-based variety, may be an important element in promoting forgiveness. McCullough ME, Bono G, Root LM (2007). Rumination, emotion, and forgiveness: Three longitudinal studies. J of Personality and Soc Psych 92 (3): 490-505.)

Neuropsychology of Forgiveness

With the growing evidence of the benefits of forgiveness on the body as well as the boom in neuroplasticity research, it seems natural to wonder what impact forgiveness may have on the brain. Yet to date, only a few articles have addressed this specific topic. In 2001, Farrow et al. asked ten subjects to read about and then form judgments on several moral situations. They used functional magnetic resonance imaging (fMRI) to look for correlations between their subjects’ self-reported judgments and brain activity. Judgments that the situations were forgivable activated four brain regions: the left superior frontal gyrus, the orbitofrontal gyrus, the posterior cingulated gyrus, and the precuneus. They suggest that all of these regions are involved in social cohesion. Other psychologists have analyzed the growing body of research on the brain and speculated about the ways that what we are learning may be relevant to the study of forgiveness. For an overview of this topic see Worthington E, Witvliet CVO, Pietrini P, Miller, AJ (2007). Forgiveness, health, and well-being: A review of evidence for emotional versus decisional forgiveness, dispositional forgivingness, and reduced unforgiveness . J of Behav Med 30 (4): 291-302.

True/False Comprehension Quiz

While different cultures vary regarding many psycho-spiritual dimensions, they’re all pretty much the same when it comes to
forgiveness.

TrueFalse

Group and individual interventions are equally
effective.

TrueFalse

Both studies that examine the mental health
benefits of forgiveness as a personality trait and those that measure the
mental health benefits of forgiveness interventions show decreases in the
incidence of depression associated with forgiveness.

TrueFalse

In a study of Fred Luskin’s psycho-educational
forgiveness intervention, participants who tested high for anger expression
pre-intervention were found to have a reduction of hypertension after the
intervention as compared to before.

TrueFalse

The research the past several decades on the
mental and physical health benefits of forgiveness have added a new dimension
to the factors that may motivate people to forgive.

TrueFalse

At present there is a large body of evidence
showing the neurophysiological details of process of forgiveness.

TrueFalse

Mindfulness meditation has already been
successfully incorporated into forgiveness interventions.

TrueFalse

Victims who ruminate angrily about their painful
experiences at the hands of others are more likely to forgive their offenders than those who don’t ruminate.